(Nisha) Pulmonology p159- 176 Flashcards
Community acquired pneumonia occurs (timeframe)
before hospitalization or within 48 hrs of hospital admission
What is the most common cause of CAP?
Streptococcus pneumoniae
Presentation of pneumonia ?
fever, cough, dyspnea, dullness to percussion, bronchial breath sounds, egophony, tachycardia, hypotension, tachypnea, change in mental status, rales, rhonchi, crepitation, chills or rigors
chills or rigors are a sign of
bacteremia
Chest pain from pneumonia (what characteristic) ?
pleuritic, changes with respiration
how do you distinguish pneumonia from bronchitis ?
Abnormal chest x-ray + dyspnea, high fever
What infections cause dry or nonproductive cough?
Mycoplasma, viruses, coxiella, pneumocystics, chlamydia
Initial diagnostic tests for all respiratory infections?
Chest X-Ray
How do you determine a specific etiology for respiratory infections?
Sputum gram stain and culture
An organism that is not visible on gram stain and not culturable on standard blood agar causes what type of pneumonia ?
Atypical Pneumonia
Atypical pneumonia x-ray findings? specific exam finding? what organisms?
bilateral interstitial inflitrates, nonproductive cough, (Mycoplasma, viruses, coxiella, pneumocystis, chlamydia)
In infectious diseases, the radiologic test is never the most accurate answer. True or false?
True
Blood cultures are positive in ___% to ___ % of cases of CAP
5-15
Hemophilus influenza is associated with ?
COPD
Staphylococcus aureus is associated with ?
A recent viral infection (influenza)
Klebsiella pneumonia is associated with ?
Alcoholics and diabetics,
Hemopytsis from necrotizing disease, currant jelly sputum
Anaerobes is associated with?
Poor dentition, aspiration
Foul smelling sputum, “rotten eggs”
Mycoplasma pneumonia is associated with ?
Young, healthy patients
Dry cough, rarely severe, bullous myringitis
Chlammydophila pneumonia is associated with ?
hoarseness
Legionella associated with?
Contaminated water sources air conditioning, ventilation sources
GI symptoms (abdominal pain, diarrhea), or CNS symptoms such as headache and confusion
Chlamydia psittaci is associated with ?
Birds
Coxiella burnetti is associated with?
Animals at the time of giving birth, veterinarians, farmers
Pneumocystis is associated with?
AIDS with <200 CD4 cells
Empyema tx?
Thoracocentesis
LDH level in Empyema?
LDH >60% and protein>50% WBC >1000/microliter
pH <7.2
When do you do a bronchoscopy for pneumonia?
Severe disease when someone is placed in ICU and initial testing such as sputum stain and culture and blood cultures do not yield an organism + the patients condition is worsening despite empiric therapy
Dx test for Mycoplasma pneumonia?
PCR, cold agglutins, serology, special culture media
Dx test for chlamydophila pneumonia ?
rising serologic titers
Dx test for legionella?
Urine antigen, culture on charcoal yeast agar
Dx test for chlaymdia psittaci?
rising serologic titers
Dx test for coxiella burnetti?
rising serologic titers
Dx test for pneumocystis jiroveci (PCP)?
BAL
It is the severity of the disease (pneumonia) that drives the initial therapy. true or false?
true
a- Strep. Pneumoniae b- Staph. Aureus c- Strep. Viridans d- Providentia stuartii e- Actinomyces israelii f- Hemophilus ducreyi g- Neisseria meningitides h- Listeria monocytogene
1- 30 y/o female with MVP, MR develops fever, anorexia & weight loss after a dental procedure
2- 80 y/o male hospitalized for hip Fx, has foley cath. in place, develops shaking chills, fever & hypotension.
3- young man develops painless, fluctuant, purplish lesion over mandible, after several weeks cutaneous fistula is noted.
4- sickle cell patient presents with high fever, toxicity signs of pneumonia & stiff neck.
C,D,E,A
Outpatient treatment of pneumonia for mild symptoms?
macrolide (azithromycin or clarithromycin) or doxycycline
Outpatient treatment pneumonia with comorbidities or antibiotics in the past 3 months?
Respiratory fluoroquinolones (levofloxacin or moxifloxacin)
Inpatient treatment for pneumonia?
Respiratory fluoroquinolones (levofloxacin or moxifloxacin) or ceftriaxone and azithromycin
______ and ______ as single factors are reason to hospitalize a patient
Hypoxia and Hypotension
List all the reasons to hospitalize a patient?
Hypotension (<90 systolic) RR (above 30) or PO2 less than 60 mmhg pH < 7.35 Elevated BUN above 30 mg/dL, sodium <130 mmol/L, glucose above 250 mg/dL Pulse above 125 per minute Confusion Temperature above 104F Age 65 or older or comorbidities such as cancer, COPD, CHF, renal failure, liver disease
CURB65 mneumonic for admission
Confusion Uremia Respiratory distress BP low Age >65
Pleural effusion with pH <7.2 suggests ? Tx?
Empyema, chest tube drainage
LDH > 60% of serum or protein >50% of serum suggests?
Exudate, exudates are caused by infection and cancer
Pneumococcal vaccination indicated in ?
Everyone above age 65 with the 13 polyvalent vaccine followed by 6-12 months with the 23 polyvalent vaccine.
Chronic heart, liver, kidney or lung disease (including asthma) should also be vaccinated regardless of age
Functional or actual asplenia
Hematologic malignancy (leukemia, lymphoma)
Immunosupression (DM, alcoholics, corticosteroid users, aids or HIV +)
CSF leak and cochlear implantation recipients
Hospital acquired pneumonia (timeframe)
More than 48 hours after admission or after hospitalization in the last 90 days
What bacteria causes hospital acquired pneumonia?
Gram negative (e-coli, pseudomonas)
Treatment for hospital acquired pneumonia?
Antipseudomonal cephalosporin - Cefepime or ceftazidime
Antipseudomonal penicillin - piperacillin/tazobactam
Carbapenems - imipenem, meropenem or doripenem
Patient in the hospital has a high fever, rising WBC count, new inflitrate on chest xray, purulent secretions from the endotracheal tube. what is your diagnosis?
Ventilator associated pneumonia
Diagnostic tests for Ventilator associated pneumonia?
Tracheal aspirate, BAL, protected brush specimen, video assisted thoracoscopy, open lung biopsy
The most accurate diagnostic test for ventilator associated pneumonia ?
Open lung biopsy (greater morbidity)
TX for ventilator associated pneumonia?
combo of 3 different drugs
1. antipseudomonal beta lactam (cepholospirin - ceftazidime/cefepime) (penicillin - piperacillin/tazobactam) (carbapenem - imipenem, meropenem, doripenem)
plus
- second antipseudomonal agent
(aminoglycoside - gentamicin or tobramycin or amikacin) or fluoroquinolone (ciprofloxacin or levofloxacin)
plus
- methacillin resistant antistaphylococcal agent (vancomycin or linezolid)
Side effect of imipenem?
Seizures, renal failure (toxicity)
Can you give daptomycin for lung infection?
NO, daptomycin is inactivated by surfactant
Lung abscess occurs in patient with ?
Poor dentition, large volume aspiration (strokes with loss of gag reflex, seizures, intoxication, endotracheal intubation)
Aspiration pneumonia occurs in what lobe?
Upper lobe when lying flat
Foul smelling sputum, weight loss + any risk factor that leads to aspiration?
Lung abscess
Diagnostic test for lung abscess? initial? accurate?
Initial - chest x-ray
Accurate - chest CT but only a lung biopsy can establish specific microbiologic etiology
Treatment for lung abscess?
Clindamycin or penicillin
Pneumocystis pneumonia occurs exclusively with AIDS whose CD4 count is less than. ?
200/ microliters
AIDS patient dyspnea on exertion, dry cough, fever. CD4 count less than 200/microliters
PCP
initial diagnostic tests for PCP? and what will you see on this imaging modality?
Chest X-ray. Bilateral inflitrates or an ABG looking for hypoxia or an increased A-a gradient
Are LDH levels elevated in PCP?
Yes
Most accurate test for PCP
BAL
If the sputum stain is positive or pneumocystis, should you do further testing?
NO
A negative sputum stain in PCP means you should answer ?
Bronchoscopy as the best diagnostic test
Normal LDH….is PCP likely?
No
Treatment for PCP?
TMP/SMX is best initial therapy and propylaxis. Add steroids to decrease mortality if PCP is severe.
What is severe PCP?
Po2 <70
A-a gradient >35
If the PCP is mild, meaning only mild hypoxia…you can use what drug?
Atovoquone
If there is toxicity to TMP/SMX, switch treatment to ?
Clindamycin and primaquine
or
Pentamidine
Most common adverse effect of TMP/SMX
Rash
Second most common adverse effect of TMP/SMX
Bone marrow supression
G6PD deficiency + PCP + rash, what drug do you give for PCP?
IV Petamidine
PCP prophylaxis is started when CD4 count is below?
200/microliter
PCP prophylaxis started when CD4 count is below
200/microliter
What do you use for PCP prophylaxis?
- TMP/SMX
if there is a rash or neutropenia
- Atovaquone or dapsone
if the CD4 count is maintained above 200/microliter for several months, should you continue PCP prophylaxis?
No
TB risk factors ?
Recent immigrants (in the past 5 years), prisoners, HIV positive, healthcare workers, close contacts of someone with TB, steroid use, hematologic malignancy, alcoholics, diabetics
PPD risk factor + fever, cough, sputum, weight loss, hemopytsis, and night sweats?
Tuberculosis
Best initial test for Tuberculosis?
Chest X-ray
What do you do after Chest X-Ray?
Sputum stain and culture specifically acid fast bacilli (myobacteria) must be done 3 times to fully exclude TB
Most accurate diagnostic test for TB?
Pleural biopsy
Treatment for TB?
RIPE (rifampin, isoniazid, pyrazinamide, ethambutol)
After using RIPE for 2 months, you use what two drugs?
RI (rifampin and isoniazid) for 4 months
Standard of care is __ months of therapy for tuberculosis?
6 months
Treatment is extended to >6 months for ?
osteomyelitis, miliary tuberculosis, meningitis, pregnancy or any other time pyrazinamide is not used
All TB medications cause what type of toxicity?
Hepatotoxicity, but do not stop TB medications until transaminases rise 3-5x the normal limit
Rifampin toxicity? how to manage it?
Red color to body secretions. No management , it is a benign finding
Isoniazid toxicity? how to manage it?
Peripheral neuropathy. Use pyridoxine to prevent
Pyrazinamide toxicity? How to manage?
Hyperuricemia. No treatment unless symptomatic
Ethambutol toxicity? How to manage it?
Optic neuritis/color vision. Management decrease dose in renal failure.
Why are steroids used in TB?
Glucocorticoids decrease the risk of constrictive pericarditis. Decrease the risk of neurologic complications in TB meningitis.
Do not give pyrazinamide or streptomycin to pregnant patients. true or false?
True
Is PPD testing useful in those who are symptomatic or those with abnormal chest x-rays?
No. These patients should have sputum acid fast testing done.
What is a positive PPD test in a patient with no risk factors ?
Induration larger than 15 mm
What is a positive PPD test in recent immigrants, prisoners, healthcare workers,close contacts of someone with TB, hematologic malignancy alcoholics and diabetics ?
Induration larger than 10 mm
What is a positive PPD test in HIV patients, glucocorticoid users, close contacts of those with active TB, abnormal calcifications on chest x-ray, and organ transplant recipients?
Induration larger than 5 mm
Two stage testing of PPD?
If patient never had a PPD test, a second test is indicated in 1-2 weeks if first test is negative. (first test may be falsely negative). If the second test is positive, the first test was a false negative.
What blood test is equal to a PPD?
Interferon gamma release assay (IGRA)
Treatment for a Positive PPD or IGRA?
After active tuberculosis has been excluded with chest x-ray, patients should receive 9 months of isoniazid.
A positive PPD confers a ___% lifetime risk of tuberculosis.
10%
Isoniazid should be combined with _____
pyridoxine
how often should healthcare workers have PPD done?
done every year
Once a PPD is positive, it will always be positive in the future. True or false?
True
If the first PPD is positive, should you do a second one?
Not neccesary
A 45-year-old Haitian immigrant presents to the emergency department with a chief complaint of productive, blood-tinged cough for 2 months. He has been in the United States for 1 month. His temperature is 40.1°C (104.2°F) and heart rate is 105/min. On physical examination he ap- pears cachectic, and pulmonary rales are heard throughout his lung fields. X-ray of the chest re- veals multiple bilateral upper lobe cavitary le- sions with associated intrathoracic adenopathy. Results of sputum culture are pending. Which of the following tuberculosis medications can potentially cause optic neuritis? (A) Ethambutol (B) Isoniazid (C) Levofloxacin (D) Pyrazinamide (E) Rifampin (F) Streptomycin
A
A 35-year-old homeless man presents to the emergency department with chief complaints of a cough and fever. He is intoxicated. He ad- mits to drinking about a fifth of vodka every day and confirms a history of delirium tremens and blackouts. X-ray of the chest is significant for an air-fluid level in the superior segment of the right lower lobe. Which of the following is the most appropriate first-line agent for treating this patient’s condition? (A) Azithromycin (B) Clindamycin (C) Isoniazid (D) Moxifloxacin (E) Piperacillin-tazobactam (F) Trimethoprim-sulfamethoxazole
B
